Alaska's Child Nutrition Programs use the Medical Statement to Request Special Meals and/or Accommodations when a child or adult in a school, child care or adult care program needs a modified diet because of a disability. A clinician meets it when a parent brings it from the school or care provider. The completed statement tells the meal program what to omit, what to substitute, and which textures or equipment are needed.
The school or agency fills in its name and site, and the parent or guardian is named on the form. A recognized medical authority (licensed physician, physician assistant, nurse practitioner or registered dietitian) completes the medical sections and signs.
Download the current version from the source each time; forms change without notice.
Medical Statement
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A state-recognized medical professional with prescriptive authority, such as a licensed physician, physician assistant or nurse practitioner, or a registered dietitian. A parent or legal guardian may sign only for a fluid milk substitution for a child with special needs that are not a disability.
Yes. The Alaska Department of Education and Early Development posts a Spanish version of the Medical Statement as a Word document on its National School Lunch Program page, alongside the English PDF and a food allergy and anaphylaxis emergency care plan.
It names the disability or condition and why it restricts the diet, the major life activity affected, the specific diet or accommodation, the texture required, foods to omit with suggested substitutions, and any equipment needed to help the participant eat.